The XX Factor

Huge DOJ Study on Rape Exams: We Have Work to Do

Barack Obama signs the reauthorization of the Violence Against Women Act in 2013.

Photo by Alex Wong/Getty Images

Today the Department of Justice released a comprehensive, 130-page study on rape exams—who has access to them, who should pay for them, and directions for the future. In part, the report examines how states are meeting the requirements set by 2005’s Violence Against Women Act, which mandates that sexual assault victims receive medical forensic tests (or MREs: these result in the rape kits we’ve heard a lot about this year) regardless of whether they go to the police. (Of the estimated 270,000 sexual assaults committed against women ages 12 and older every year, about one-third get reported to law enforcement.) To build the report, researchers conducted nationwide surveys of healthcare providers, police departments, victim advocates, state fund administrators, and other relevant personnel. Then, guided by those results, they ran interviews and crafted case studies in six states. The conclusions are wide-reaching, sometimes heartening,  sometimes troubling. They show the places where existing policies are functioning smoothly and illuminate areas for improvement. Here’s what you should know.

First off, the study investigated how states are paying for MREs. The most common source of cash proved to be victim compensation funds, or stores of money set aside by the state to recoup victims for their losses: 34 states drew at least in part on these pools, and 19 relied on them exclusively. Alternatives include law enforcement and prosecution funds, which are currently utilized in whole or part by 11 states. The authors argue that these substitute options should be tapped more frequently to ensure adequate coverage—in many cases, they write, MREs cost more than what’s allowed by state-prescribed payment caps on the public money that can be funneled from the compensation funds to health providers. (Meanwhile, VAWA does not set any requirements for where rape kit funding should come from.) That means that healthcare providers must eat whatever costs are left over, or charge it to victims’ insurance (though that latter happens very rarely). The authors worry that continually forcing hospitals and clinics to absorb parts of the bill for MREs will result in fewer women helped. At the same time, researchers point to a lack of clarity among state fund administrators about what services should even be included in the test. Though rape exams are widely agreed to consist of a medical portion (identifying and treating minor injuries, testing for pregnancy and STIs, making referrals for more serious injuries) and a forensic portion (identifying and photographing injuries that imply the use of force, collecting blood or urine to test for date-rape drugs, extracting semen or saliva to establish sexual contact, harvesting DNA to place perpetrators), not all of these services get funded equally. Also, additional procedures like X-rays, CT scans, treatment for broken bones, and treatment for STIs and pregnancy, can drive up costs for both hospitals and victims. 

Despite this, the study finds that the vast majority of women across the country who seek exams receive them for free, whether or not they take their stories to the police. American rape kit providers, take a bow. And, as the authors suggest, get the word out: The more people who know that a covered MRE is not contingent on pursuing legal action, the better.

Yet the report also raises questions of access that transcend the economic. It finds that, for a variety of reasons, not all victims can obtain sexual assault exams, that the exams are not always administrated in “a culturally competent manner,” and that immigrants, American Indians, and non-English speakers face the toughest availability barriers. When victims miss out on MREs, they can’t build effective cases against the perpetrators. What’s more, the tests are crucial for connecting women with advocates who can help them navigate the legal and emotional aftermath of the assault.

Among the obstacles to access mentioned are geography—victims live too far away from a healthcare provider to procure an MRE, or the clinics near them don’t have nurses trained to deliver the exams. Also language: At the beginning of the test, the examiner (typically a nurse) conducts an interview to try to ascertain what happened. Miscommunication and misunderstanding can cloud the testimony. Finally, test givers need training to help them understand cultural differences. As the researchers write, some communities are especially driven to protect perpetrators and engage in victim blaming; some women are unlikely to know that their experience qualifies as rape. And providers’ attitudes toward marginalized groups matter: In a wrenching series of quoted accounts, American Indians report not being taken seriously, being accused of drug addiction, and being treated for illusory mental illnesses when seeking an exam. Immigrants reveal their fears of deportation and general distrust of the government. Across case studies and interviews, most women describe positive, empathic encounters with nurses, but a few do not. “The [exam] situation felt like it was happening all over again, like the assault,” one victim said. Another recounted the trauma of being forced to deal with a male photographer, despite repeated requests for a woman.

A separate chapter of the study focuses specifically on victims who choose to forgo the legal process. At least three-fourths of the women who receive MREs also report to the police. But for the one-fourth who do not, there is the question of how and where to store unreported rape kits, with their supplies of pristine evidence. In most states, law enforcement archives them without processing them. Sometimes, a medical facility will keep them instead. Storage periods range from a month to many years to indefinitely—and the hope is that, eventually, a victim will change her mind and open a case. (Some evidence erodes over time, but not all.) Instead of waiting for this to happen, though, the study’s authors recommend creating avenues for women to report crimes anonymously, so that the police can access the evidence in the kits (particularly suspects’ DNA) without violating victims’ privacy. And they suggest piloting an informal reporting method so that women can ask questions of law enforcement officers without committing to full-blown investigations.

More on the servants in blue: The study contains a dispiriting rundown of reasons women may not want to go to the police. “Whether discouraging them to report, doubting their stories, or indicating there was not much they could do,” the authors write, “some law enforcement clearly communicated to victims that their cases were unlikely to proceed.” Surveyed victims also said they experienced shame, self-blame, and fear at the prospect of involving the cops. Yet others “found the police to be supportive and encouraging, and diligent in the investigation”; these efforts “were more likely to be successful and victims were more likely to be glad they had reported,” say the researchers.

A final facet of the study looks at how the Violence Against Women Act has transformed the landscape of response to sexual assault. Passed in 2005, the law required states to have implemented its mandate—free MREs, not contingent on a police report—by 2009. So researchers asked government officials, care providers, and hospital personnel whether anything had changed in five years: Did VAWA make a difference? Was the state better able to provide free exams? Were more victims requesting exams? Were more victims reporting assaults to law enforcement? Were more victims receiving medical attention?  

“The common threads across these questions and the different types of respondents was that between approximately one-third and somewhat more than half of the respondents reported that conditions had remained the same,” the authors write. “This is not too surprising, considering that some states were already in compliance with federal standards before they took effect. Of those who reported change since January 2009, most reported that conditions had improved at least somewhat, with very few reporting that these conditions had gotten worse (although some were not able to provide an answer).”

So even as states seem to be following through with VAWA’s guidelines, the status quo hasn’t shifted significantly. That’s probably where the researchers’ recommendations—better training for nurses and law enforcement officers, more secure sources of funding, a way to encourage victims to report their experiences without offending their privacy—come in. In any case, elucidating studies like this one are as good a starting point for reform as any.